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Georgia Reimbursable Employer's Power of Attorney Form


Georgia Reimbursable Employer's Power of Attorney Form
Georgia Reimbursable Employer
WHEREAS, , has purchased in its own
name
WHEREAS, , an employer liable under OCGA Sections
34-8-33(a)(4) or (5) or 34-8-35(h) and (i) of the Employment Security Law, has elected under subsection (b) of OCGA Section
34-8-158 of the Employment Security Law to reimburse the Georgia Department of Labor an amount equal to the sum of all regular
benefiits paid and one-half of any extended benefits paid, which are attributable to service in the employ of such employer; and
GEORGIA, COUNTY
FOR DEPARTMENT USE ONLY
Attorney in Fact is hereby authorized and empowered to give notice of redemption of the subject Security to the obligor Bank in writing
and pursuant to the terms of the Security and the Rules and Regulations of their issue, upon receipt of which notice of redemption
the obligor Bank shall be authorized and directed to redeem said Security pursuant to the terms thereof and to pay all sums due
thereunder directly to the Georgia Department of Labor for application by that Department.
In the event of default by , the
(employer)
to act in its place and stead, as follows:
(employer)
appoints the Georgia Department of Labor the true and lawful Attorney in Fact for
(employer)
on behalf of , hereby constitutes and
(employer)
, pursuant to authority granted him to
NOW, THEREFORE, pursuant to the terms of the Employment Security Law:
KNOW ALL MEN BY THESE PRESENTS, that the undersigned officer of the
for safekeeping.
(Name and Address of Bank)
WHEREAS, these securities along with a copy of this Power of Attorney properly executed will be deposited in the
of total value of $ for the purpose of substituting for the above described cash deposit or surety bond; and
(Give full description of Security)
REIMBURSABLE EMPLOYER'S
POWER OF ATTORNEY
(employer)
WHEREAS, this employer has been approved under subsection (b)(5) of OCGA Section 34-8-160 of the Employment
Security Law to deposit acceptable securities in lieu of either the cash deposit or surety bond required by subsection (a); and
(employer)
GA. DOL ACCOUNT NO.
DOL-14 (R-11/08)
Georgia Reimbursable Employer's Power of Attorney Form
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